PEDIATRICS Vol. 122 No. 1 July 2008, pp. 213-214 (doi:10.1542/peds.2008-0682)
LETTER TO THE EDITOR |
Bedside Ultrasonography and Endotracheal Tube Placement: A Long Way to Go
Venkataseshan Sundaram, DMAshwani Kumar, MD
Praveen Kumar, DM
Neonatal Unit
Department of Pediatrics
Postgraduate Institute of Medical Education and Research
Chandigarh 160012, India
To the Editor.—
The study by Galicinao et al1 published in the December 2007 issue of Pediatrics is a welcome investigation into the potential use of bedside ultrasonography (BUS) for confirming endotracheal tube (ETT) placement. However, the conclusions drawn are debatable.
First, it is not clear as to what the gold standard was for confirming the ETT placement. Under "Interventions" the authors stated that the confirmation was based on direct laryngoscopy, auscultation, clinical examination, and use of a colorimetric end-tidal carbon dioxide detector (CECD). On the other hand, under the "Outcome Measures," they mentioned that results were compared with CECD and chest radiograph results. If either BUS or CECD was part of the gold standard, calculation of their own sensitivity and predictive values would be erroneous.
Second, the authors mentioned that in phase II, BUS confirmed tube placement in all cases as determined through chest radiographs and clinical examinations. Going by the nonblinded study design, if BUS did not show the tube in the trachea, reintubation would have been performed immediately. Chest radiography was performed later. It was not specified in the article if the BUS findings on first intubation attempt were analyzed separately. The reverse also seems to be true, as illustrated by the final 2 patients described by the authors. In both cases, although BUS showed "confirmatory" images, the patients were reintubated because of no change in CECD color and an absence of chest-wall movements. The change in CECD color after 10 manual breaths occurred after "reintubation." Hence, it is possible that the first intubation placed the tube incorrectly, although BUS showed "confirmatory changes."
Third, although the authors have reported that there was no correlation between the ease of imaging and cricothyroid membrane (CTM) surface area, the applicability of this technique in the neonatal population is doubtful, because in neonates, especially preterm infants, the CTM is virtually nonexistent.2,3 It would have been useful if the contribution of neonates to the study population was explicitly stated.
Fourth, the interference by the BUS probe with the intubation procedure should have been mentioned, especially if it was used during the process of intubation.
Finally, we do not agree that one can conclude from this study to start using BUS to confirm ETT placement, but what has been shown is the feasibility of performing BUS through the CTM in a wide range of pediatric patients.
REFERENCES
- Galicinao J, Bush AJ, Godambe SA. Use of bedside ultrasonography for endotracheal tube placement in pediatric patients: a feasibility study.
Pediatrics.2007; 120
(6):1297
–1303
[Abstract/Free Full Text] - Soriano SG, Kim C, Jones DT. Surgical airway, rigid bronchoscopy, and transtracheal jet ventilation in the pediatric patient. Anesthesiol Clin North America.1998; 16 (4):827 –838[CrossRef]
- Navsa N, Tossel G, Boon JM. Dimensions of the neonatal cricothyroid membrane: how feasible is a surgical cricothyroidotomy? Paediatr Anaesth.2005; 15 (5):402 –406[CrossRef][Medline]
PEDIATRICS (ISSN 1098-4275). ©2008 by the American Academy of Pediatrics
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